Prioritizing Health Care Strategies to Reduce Childhood Mortality
Authors: Zachary J. Madewell, Cynthia G. Whitney, Sithembiso Velaphi, Portia Mutevedzi, Sana Mahtab, Shabir A. Madhi, Ashleigh Fritz, Alim Swaray-Deen, Tom Sesay, Ikechukwu U. Ogbuanu, Margaret T. Mannah, Elisio G. Xerinda, Antonio Sitoe, Inacio Mandomando, Quique Bassat, Sara Ajanovic, Milagritos D. Tapia, Samba O. Sow, Ashka Mehta, Karen L. Kotloff, Adama M. Keita, Beth A. Tippett Barr, Dickens Onyango, Elizabeth Oele, Kitiezo Aggrey Igunza, Janet Agaya, Victor Akelo, J. Anthony G. Scott, Lola Madrid, Yunus-Edris Kelil, Tadesse Dufera, Nega Assefa, Emily S. Gurley, Shams El Arifeen, Ellen A. Spotts Whitney, Katherine Seib, Chris A. Rees, Dianna M. Blau, Ferdousi Begum, Mohammad Mosiur Rahman, Mohammed Kamal, A.S.M. Nawshad Uddin Ahmed, Mahbubul Hoque, Kyu Han Lee, Saria Tasnim, Mahbubur Rahman, Tahmina Shirin, Iqbal Ansary Khan, Meerjady Sabrina Flora, Dilruba Ahmed, K. Zaman, Kazi Munisul Islam, Mohammed Sabbir Ahmed, Mohammed Zahid Hossain, Mustafizur Rahman, Shahana Parveen, Sanwarul Bari, Farida Arjuman, Farzana Islam, Ferdousi Islam, Joseph O. Oundo, Gunturu Revathi, Emily Rogena, Magdalene Kuria, Paul K. Mitei, Florence Murila, Jennifer Verani, Doh Sanogo, Nana Kourouma, Seydou Sissoko, Uma U. Onwuchekwu, Diakaridia Sidibe, Tatiana Keita, Diakaridia Kone, Sharon M. Tennant, Carol L. Greene, J. Kristie Johnson, Rima Koka, Karen D. Fairchild, Sandra Lako, Erick Kaluma, Samuel Pratt, Baindu Kosia, Ruby Fayorsey, Rebecca Alkis Ramirez, Rebecca P. Philipsborn, Mischka Garel, Navit T. Salzberg, Jeffrey P. Koplan, Robert F. Breiman, Jana M. Ritter, Joy Gary, Sherif R. (deceased) Zaki, Jennifer R. Verani, Jacob Witherbee, Lucy Liu, Shailesh Nair, Jonas M. Winchell, Fikremelekot Temesgen, Melisachew Mulatu Yeshi, Addisu Alemu, Alexander M. Ibrahim, Tadesse Gure, Stian Orlien, Solomon Ali, Yunus Edrid, Mahlet Abayneh Gizaw, Fentabil Getnet, Surafel Fentaw, Celso Monjane, Sheila Nhachungue, Clara Menendez, Justina Bramugy, Milton Kindcardett, Tacilta Nhampossa, Ariel Nhacolo, Khátia Munguambe, Pio Vitorino, Carla Carrilho, Fabiola Fernandes, Sibone Mocumbi, Maria Maixenchs, Juan Carlos Hurtado, Jaume Ordi, Marta Valente, Natalia Rakislova, Dercio Chitungo, Zara Manhique, Yasmin Adam, Sanjay G. Lala, Karen L. Petersen, Peter J. Swart, Martin Hale, Jeannette Wadula, Noluthando Dludlu, Fatima Solomon, Richard Chawana, Hennie Lombaard, Gillian Sorour, Constance Ntuli
Journal: JAMA Network Open (2022)

Importance Although child mortality trends have decreased worldwide, deaths among children younger than 5 years of age remain high and disproportionately circumscribed to sub-Saharan Africa and Southern Asia. Tailored and innovative approaches are needed to increase access, coverage, and quality of child health care services to reduce mortality, but an understanding of health system deficiencies that may have the greatest impact on mortality among children younger than 5 years is lacking. Objective To investigate which health care and public health improvements could have prevented the most stillbirths and deaths in children younger than 5 years using data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network. Design, Setting, and Participants This cross-sectional study used longitudinal, population-based, and mortality surveillance data collected by CHAMPS to understand preventable causes of death. Overall, 3390 eligible deaths across all 7 CHAMPS sites (Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) between December 9, 2016, and December 31, 2021 (1190 stillbirths, 1340 neonatal deaths, 860 infant and child deaths), were included. Deaths were investigated using minimally invasive tissue sampling (MITS), a postmortem approach using biopsy needles for sampling key organs and fluids. Main Outcomes and Measures For each death, an expert multidisciplinary panel reviewed case data to determine the plausible pathway and causes of death. If the death was deemed preventable, the panel identified which of 10 predetermined health system gaps could have prevented the death. The health system improvements that could have prevented the most deaths were evaluated for each age group: stillbirths, neonatal deaths (aged &amp;amp;lt;28 days), and infant and child deaths (aged 1 month to &amp;amp;lt;5 years). Results Of 3390 deaths, 1505 (44.4%) were female and 1880 (55.5%) were male; sex was not recorded for 5 deaths. Of all deaths, 3045 (89.8%) occurred in a healthcare facility and 344 (11.9%) in the community. Overall, 2607 (76.9%) were deemed potentially preventable: 883 of 1190 stillbirths (74.2%), 1010 of 1340 neonatal deaths (75.4%), and 714 of 860 infant and child deaths (83.0%). Recommended measures to prevent deaths were improvements in antenatal and obstetric care (recommended for 588 of 1190 stillbirths [49.4%], 496 of 1340 neonatal deaths [37.0%]), clinical management and quality of care (stillbirths, 280 [23.5%]; neonates, 498 [37.2%]; infants and children, 393 of 860 [45.7%]), health-seeking behavior (infants and children, 237 [27.6%]), and health education (infants and children, 262 [30.5%]). Conclusions and Relevance In this cross-sectional study, interventions prioritizing antenatal, intrapartum, and postnatal care could have prevented the most deaths among children younger than 5 years because 75% of deaths among children younger than 5 were stillbirths and neonatal deaths. Measures to reduce mortality in this population should prioritize improving existing systems, such as better access to antenatal care, implementation of standardized clinical protocols, and public education campaigns.